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In Her Own Words

— Most Telling —

• As far as teaching the child that you [the parent] are “bigger and badder,” that is exactly what needs to be taught. — in “Ask the Doctor” (2007), The Little Prince, Surviving Life with Reactive Attachment Disorder [website 2007, accessed 29 Apr 2008]

• After a few minutes, most children become uncomfortable from being held in such an intimate position. A child may beg, plead and bargain to get out of being held. Holding therapy also allows for the safe expression of rage. The child may scream, yell, threaten, kick, bite, or hit. It is important to maintain safe holding procedures throughout this time. — Attachment Disorders: Treatment Strategies for Traumatized Children (Lanham, MD: Aronson, 2006), p. 143

• While some may suggest that holding therapy is unhumane, I believe a successful recovery from RAD depends upon holding therapy. — Attachment Disorders (2006), p. 144

• Some attachment therapists suggest taking everything away from a child except the basic necessities of life, and possibly even limiting these basic necessities if the situation calls for it. I have found this to be a powerful strategy… — Attachment Disorders (2006), p. 135

• When a new set of foster caregivers took [the boy] in, I had them take everything away right down to the bare mattress on the floor and a bucket to sit on. His caregivers picked out what he would eat, what he could do and what he could wear. He had to ask permission to talk or to use the bathroom. — Attachment Disorders (2006), p. 137

• I suggested to the family that they take all items out of [the girl’s] room and put a lock on her closet so there would be no place to hide panties. They did this, leaving [the girl] only a mattress and blanket. We promised [her] that she could have all of her personal items back once she mastered controlling her urge to soil and hide her panties. — Attachment Disorders (2006), p. 176

• Taking away that control calls for drastic measures. You stated that you felt Nancy Thomas’ strategies sounded abusive. I have heard that many times but if you want to beat RAD, her strategies cure RAD. I use them and promote them all the time. — “Ask the Doctor” (2007)

• By taking away control, I mean taking away the right to decide anything: what to do, what to eat, when to go to bed, what to wear — everything! — Attachment Disorders (2006), p. 133

• I am currently counseling a family in Canada, east TN, Brazil, and California on RAD. … Sometimes families send me videotape of the child so I can see the problems first hand. — “Ask the Doctor” (2007)

— Holding Therapy —

• Holding therapy involves putting the child into an infant-like hold, either cradled in the caregiver’s arms or with the child’s head on the caregiver’s lap so that eye contact can be facilitated. This creates a sense of dependency and vulnerability much like a young child experiences early in life and emulates the trust cycle. — Attachment Disorders (2006), p. 143

• I like holding therapy because it brings results faster… — “Ask the Doctor” (2007)

• Holding Therapy is a very useful tool for creating a healthy bond between a caregiver and a child. — “Ask the Doctor” (2007)

• [O]ne of the cornerstones of treatment of RAD is for the child to re-experience the trauma and its meaning. — Attachment Disorders (2006), p. 147

• Holding therapy is often difficult for parents to witness or accept at first because of the intensity of emotion that is involved. — Attachment Disorders (2006), p. 144

• [In Holding Therapy] … The child’s need to control is so and intense distrust in those around him causing the child to fight an emotional connection with everything they have. — Attachment Disorders (2006), p. 109

• Holding therapy requires the supervision of a therapist who specializes in RAD. I hope you are in contact with one. If this boy is falling asleep or shutting down before the rage is resolved the holdings will be ineffective. — “Ask the Doctor” (2007)

• Just as a raging infant is held lovingly, supported, and comforted while she goes through this process, so should a raging child or teen be treated in the same way… — Online Class [2007], Lesson #6 [also Attachment Disorders (2006), p. 109)

— Attunement —

• Synchronize your breathing to the child’s breathing and your movements to the child’s movements. Wait for your child to notice. — Online Class [2007], Lesson #5

• I also do attunement activities during holdings … which is a critical part of attachment therapy in my opinion. During holding times, I take care of every single need the child has, such as scratching their nose if it itches, or wiping away sweat from the child’s forehead, or comforting a stiff neck with a pillow. — Online Class [2007], Lesson #6

— In Therapy —

• I continue to press the issue with [the child], discounting all of her excuses, and slowly taking away all of her defenses. — Online Class [2007], Lesson #6

• Occasionally, a child may rage over an hour but most of the children I have worked with run out of energy after thirty to forty-five minutes. … The more sophisticated the child, the more he will try to beg, argue, negotiate, plead, or promise his way out of the situation. The Broken Record Technique is useful when this happens. … Often, the child will try to manipulate others into responding to their plight by yelling or calling out that they are being hurt. … Once the rage is over, I have the child strong sit. … It is important to make sure the child gives 100% total compliance… — Online Class [2007], Lesson #6

• Billy [8yo] then started squirming, crying that he had to go to the bathroom really bad. … I told him he could wet himself if he wanted to, or he could quickly tell me the real story of what happened with his foster mother and then I would take him to the bathroom. (Sometimes children will wet themselves intentionally, hoping to get out of taking responsibility for their actions. I have had children vomit as well.)
  When not allowed to use the bathroom, Billy tried to flee the room. When I stopped him, he kicked, screamed, scratched, yelled, and raged. I restrained him, and calmly told him that I would keep us both safe until he was done raging.…
  — Attachment Disorders (2006), p. 161

• After some time, Billy complied with strong sitting but claimed that he could not cross him legs because they were asleep from the earlier restraint hold. I told him he needed to cross his legs regardless of how they felt. This procedure was continued until Billy gave 100 percent compliance, at which time Billy stated that he had now forgotten how the incident with his foster mother had happened. I calmly told him that I would wait for him to remember what had happened and that I would cancel my next appointment if necessary to give him time to remember.
  It is important to get 100 percent compliance with strong sitting … The same applies to Billy’s assertion that he had to use the bathroom. He may very well have developed the urge to use the bathroom during the course of therapy, but it is important to delay going to the bathroom until the issue is dealt with because, more likely than not, the child is trying to control the situation.
  — Attachment Disorders (2006), p. 162

— On Physical Restraint —

• [C]onfronted with this type of intervention. I did have one five-year-old who took four hours to self-control but he also had been diagnosed with Autism. — Online Class [2007], Lesson #6

— “Contracting” with Children —

• Contracting Questions

• Are you happy?

• Are you partly unhappy with yourself?

• Do you want to work on it?

• Do you want to work hard?

• Do you want to work hard my way? — Attachment Disorders (2006), p. 112

—Controlling with Food —

• Children should not be allowed to eat their food until they are 100% clean. That means scrubbed, combed, and in clean clothes. There should be no nagging or reminding. If a child comes to the table without having cleaned herself, simply remove her plate without saying anything. — Online Class [2007], Lesson #6

• Some times it is helpful to set a time, such as twenty minutes, for the child to finish eating and then take the plate away. — Attachment Disorders (2006), p. 177

• I know kids who have manipulated these strategies to their own benefit, sometimes by going to school and telling a staff member that they had not been allowed to eat before coming to school… — Attachment Disorders (2006), p. 177

— More on Controlling —

• Only when the child gives in to the idea that control belongs to the adult, can healing begin. If you cannot take away the control, you might as well give up. One of the foster mothers I recently worked with established the number-one rule in her home as, “I am the boss and your job is to learn to love it.” — Attachment Disorders (2006), p. 135

• The important thing is for the adult to “win” the battle of control. — Online Class [2007], Lesson #6

• Typically, when control is taken away, the child will begin to use the skills she has used in the past to get her way, such as whining, threats, manipulation, charm, promises, begging, etc. When these tactics don’t work, the child becomes desperate … … Some children will try to kill themselves. — Online Class [2007], Lesson #6

• It is enough to say, “Because I told you to.” when the child asks why she must do what she has been told to do. — Online Class [2007], Lesson #5

• I advise parents … to teach the child to say “Yes, Dad” or “Yes, Mom,” to every single direction … Not only does this response show respect for the one in authority, but saying yes also verbally relinquishes control to the adult. — Attachment Disorders (2006), p. 136

— Alarms —

• Families are at risk during this period of time when control is being transferred from the child to the adults. Because the child with RAD must search for new ways to gain control or seek revenge, he may up the ante. During this stage, I have had children as young as three try to kill their caregivers or siblings during the night. I advise caregivers to install alarms on the child’s bedroom door at night… — Attachment Disorders (2006), pp. 135-136

— Strong Sitting —

• Strong sitting, a technique introduced by Nancy Thomas… — Online Class [2007], Lesson #6

• Tell [the boy] he will practice for ten minutes and set a timer for that amount of time. Be specific in your expectations, such as, your feet must remain on the floor, your hands must be in your lap, your head must be up and your mouth must be closed with no talking. Tell [him] that if any of these rules are violated, the ten minutes will start over… — Online Class [2007], Lesson #5

• I prefer to have a child do strong sitting facing a blank wall because so many children can entertain themselves with visual stimulus, thus making the strong sitting ineffective. — “Ask the Doctor” (2007)

• Strong sitting is not used as a punishment. — Attachment Disorders (2006), p. 146

— “Broken Record Technique” —

• The act of making a simple statement and then keep repeating that same statement in a neutral tone of voice when a child tries to engage you in argument or discussion. — Attachment Disorders (2006), p. 187

— Attachment Therapy Parenting —

• If the child does not complete the chore to the best of his ability, he is to redo the chore and a privilege is taken away and another chore assigned. No excuses are accepted for not having the chore done correctly and to the best of the child’s ability. — Attachment Disorders (2006), p. 124

• I suggest that the child provide restitution at one-and-one-half to two times the going rate. — Attachment Disorders (2006), p. 144

• RESTITUTION … I suggest having the child give the caregiver a back rub or foot massage… — Online Class [2007], Lesson #6

• Families should eliminate as much change and novelty as possible in the early stages of treatment … This includes having a strict schedule that does not alter or change. That might eliminate having or going to birthday parties, participating in holiday celebrations or attending exciting activities such as fairs and recreational parks… — Attachment Disorders (2006), p. 182

• A child who cannot stop talking should be encouraged to put her hand over her mouth for a few minutes as a way of learning control. — Online Class [2007], Lesson #6

— Humiliation —

• For example, if [the boy] could go ten days without an angry blow up, he could earn the right … to use a chair when eating dinner with the family. — Attachment Disorders (2006), p. 137

— Play —

• [W]hen forced to go through a playful experience, the child most often develops the desire to play on his own. — Online Class [2007], Lesson #6

— School —

• [H]ave the teacher talk with the class to not share their food with her. — “Ask the Doctor” (2007)

• I am often asked by children in my clinical practice why they should have to respect a teacher that treated them unfairly … I remind the child that the teacher is an adult with higher status, no matter what the teacher has done, while the child is at a lower status until he becomes an adult on a more equivalent social level. I liken this to the teacher being the “queen” while the child is simply a “servant” at this point in time, thus, no matter what the queen does, the child must respect her simply because she is the queen. — Online Class [2007], Lesson #6

• The school staff needs to be aware that disciplinary strategies used for children with RAD are very different than those used with the general population. … In many RAD cases. … [A]n immediate consequence is warranted rather than a second chance. — “Ask the Doctor” (2007)

• Unfortunately, the general public, and even some good therapists, often don’t understand that the strategies used with RAD need to be very different from traditional behavior management techniques. I write letters of support for the families I work with to DCS, schools, or other concerned parties and this usually takes care of the problem. Please be careful as I have seen children removed from their parents for months and put into foster care because they were doing just what you are doing. Do you have a therapist that can support you? — “Ask the Doctor” (2007)

— The “Trust Cycle” —

• Only when the child can relinquish control and give it back to the caregiver, will the trust cycle be re-established. In other words … the child must learn to depend on the adult to get that need met. — Online Class [2007], Lesson #6

• There are four components of the Trust Cycle: 1) need on the part of the infant (e.g., hunger, needing a diaper changed); 2) emotional response (e.g., crying, fussing); 3) Gratification (e.g., the caregiver provides food or comfort); and 4) trust (e.g., the child learns that someone will help him in a time of need). … The Trust Cycle … is adapted from the work of Foster Cline. — Attachment Disorder (2006), pp. 18-19

• In the Trust Cycle, the infant has a physical need, such as hunger. … The hunger causes an emotional reaction in the child, such as rage or fear. — Online Class [2007], Lesson #1

— Belief in Catharsis and Provoking Anger —

• Anger is energy, as is sadness and depression. I teach the children to release that energy. … [W]ork or exercise help release the pent up negative energies… — Online Class [2007], Lesson #6

• [L]etting this rage out in a safe, controlled environment is often therapeutic. — Attachment Disorders (2006), p. 159

• Children with RAD often thrive on their anger. It is like an addiction and fuels their energy. They are not willing to give it up. … A child with anger problems can typically be provoked to anger while engaged in play. Just beating a child at a board game is enough to bring anger to the surface in some cases. If not, and “accidental” bump of a board game so that the pieces are scattered and the game must be started over when the child was winning typically will do the trick. — Attachment Disorders (2006), p. 158

— “Transferred Bond” —

• Yes! I have successfully bonded children to me or staff and then transferred the bond to the parent or foster parent. We had the children for at least 10-12 hours a day. I believe your therapist is “right on” suggesting you to send the child to a respite parent that is trained to do this. I know it sounds counterintuitive. — Online Class [2007], General Discussion

— “Attachment Disorder” —

• Enuresis or Encopresis … I often see children with RAD who continue to have toileting issues into their teens. — Attachment Disorders (2006), p. 175

• Symptoms of an Attachment Disorder…
  Symptoms of RAD [Reactive Attachment Disorder]…

• Destructive to self, property or others
• Intense anger, rages, or temper outbursts
• Aggressive, fighting, bullying
• Withdrawing or dissociating
• Deceitfulness and lying, conning…
• Inappropriate sexual conduct
• Cruelty to animals…
• Hyperactivity, fidgety, tense, on the go all the time
• Talks in overly loud voice
• Rarely smiles or laughs
• Abnormal eating habits
• Persistent nonsense questions and chatter
• Poor hygiene…
• Lack of cause-effect thinking…
• Learning or language disorders or difficulties
• Plays the victim
• Grandiose sense of self-importance
• Not affectionate on caregiver’s terms…
• Frequent sadness, depression, or hopelessness…
• Lack of eye contact or looks right through you…
• Exploitative, manipulative, controlling, and bossy
• High pain tolerance and accident prone…
• Genetic predispositions
• Identification with evil & the dark side of life, blood, or gore…
• Lack of remorse or conscience
• Repression (pushing experiences deep in the psyche)… — Attachment Disorders (2006), pp. 94-96

— Scare Tactics —

• Children with RAD will sometimes identify with evil superhero figures or with evil people of the past and present, such as Adolf Hitler or Saddam Hussein. — Attachment Disorder (2006), p. 168

• I cannot count on my fingers how many parents have related horror stories of finding their child standing over them during the night with a knife or scissors in his hand. — Attachment Disorder (2006), p. 120

• I advise caregivers to … keep eyes in the back of their heads to avoid being attacked from behind. — Attachment Disorders (2006), pp. 135-136

• The child also learns to manipulate … other human beings, using charm, aggression, wit, conning… — Online Class [2007], Lesson #1

• The child who does not respond is most often controlling you by not responding. — Online Class [2007], Lesson #6

• Many children with RAD have the uncanny ability to charm unsuspecting victims. — Attachment Disorder (2006), p. 167

• [T]he child is able to put on a carefully construed false front in order to manipulate the social worker. — Attachment Disorder (2006), p. 44

— Eye Contact —

• Children with RAD often lack eye contact, or learn to “mask” the emotions in their eyes as if shielding the world from their inner soul. — Online Class [2007], Lesson #1

• From day one, expect and demand eye contact. — Online Class [2007], Lesson #6

• Eye contact is greatly facilitated during holding therapy, when the child is placed in a position were face-to-face engagement occurs. — Online Class [2007], Lesson #1

— Magical Transformational Thinking —

• When a child draws a gruesome picture, say of a bloody knife or a monster killing people, I have them take that same drawing and turn the object into something positive. The blood on the knife can be turned into strawberry sauce on ice cream, or the monster can don wings and angel dust and turn into a monster of mercy instead of one of prey. — Attachment Disorders (2006), p. 149

— Brain Nonsense —

• Children with self-regulation problems often has difficulty knowing where their body is in space and time. — Attachment Disorders (2006), p. 157

• Holding therapy may result in the brain going into twelve to fifteen hertz, the brain pattern of relaxation, the child can then begin to recognize the holding for what it is and to understand that physical intimacy is not a threat. — Attachment Disorders (2006), p. 144

• In fact, the abused child probably develops several responses in case the first response does not work. … Each time the brain switches programs, the selected program must be aborted, a new pattern must be detected, another program selected, and implemented. — Online Class [2007], Lesson #2

• Eye contact helps the child bond to the parent and helps the child organize her brain based on the organizational structure of the caregiver. — Online Class [2007], Lesson #6

— Military Camp —

• As far as a military camp, I have found these to be highly successful with RAD kids simply because they put such strict boundaries and expectations on the kids. — Online Class [2007], General Discussion

— Recommended Therapies and Philosophies —

• I recommend Nancy Thomas’ website to find an attachment specialist near you if you do not already have one, but be careful, I am hearing more and more about unskilled, untrained people who call themselves attachment specialists who really aren’t. For those of you who are interested, I have provided online monitoring with families via webcam sessions. — “Ask the Doctor” (2007)

• I would suggest that you look into Evergreen Colorado’s Attachment Center [renamed Institute for Attachment and Child Development] and the work of Terry Levy, Foster Cline, Daniel Hughes, Nancy Thomas and some of the “greats” in attachment to make sure the facility you are using follows this type of philosophy (particularly Terry Levy and Foster Cline for the holding therapy). Also look at ATTACh’s [Association for Treatment & Training in the Attachment of Children] model, which is a real good one. — “Ask the Doctor” (2007)

• I am wondering the pros and cons of the therapeutic respite approach with other methods such as the Evergreen Attachment Center [i.e., Institute for Attachment and Child Development] in Colorado where a whole family attends for 2 weeks and participates in an intensive course. One concern is the prohibitive cost of $10,000 and that doesn’t begin to include travel and other expenses. The therapeutic respite, while not cheap, is more affordable at $100 a day. — Online Class [2007], General Discussion

— Recommended Reading —

• Martha Welch, Holding Time

• Foster Cline, Conscienceless Acts Societal Mayhem: Uncontrollable, Unreachable Youth and Today’s Desensitized World

• Lynda Gianforte Mansfield & Christopher H. Waldmann, Don’t Touch My Heart: Healing the Pain of an Unattached Child

• Deborah D. Gray, Attaching in Adoption

• Nancy Thomas, When Love Is Not Enough — Pediatric Behavioral Health Resources (website 2006; accessed 29 Apr 2008)